Psychotherapy Techniques for Patients Diagnosed with Schizophrenia

Introduction

In this paper I will describe how standard psychotherapy technique should be modified in working with patients diagnosed with schizophrenia. The mental operations of patients with psychosis often differs significantly from those who have neuroses, and it would, therefore, make sense that a traditional psychotherapy approach, designed for patients with neurosis, would need to be modified for work with patients with psychosis. For example, since the use of language is often compromised in patients with psychosis, we cannot use a standard psychodynamic approach, which is based upon intact language use.

How then, should we approach work with patients who have schizophrenia? Our long-term goal may be symptom reduction and better psychosocial adaptation. However, we are unlikely to reach that goal if the patient cannot participate in a verbal process. At the start, our interim goal, our fundamental practical goal, is to help the patient put his experience into words. Without this, the patient’s capacity for psychological change is severely limited.

The Structure of the Mind in People Diagnosed With Schizophrenia

If the mind in schizophrenia is organized differently than it is in neurosis, then an effective psychotherapy must take this different mental structure into account.

I will describe the mental organization which characterizes schizophrenia. Typically, there are five areas of major disturbance. These are:

Disturbance in the Capacity for Emotional Attachment

Patients with schizophrenia establish relationships very cautiously. These connections are painstakingly made and tentative. They are extremely vulnerable to being disrupted, and the patient can withdraw from them abruptly, massively, and permanently. This is one of the biggest problems for psychotherapy with these patients—a slight, a fear, a painful fantasy distortion can lead the patient to abandon the relationship suddenly. The fear of being personally exploited may be so intense that the patient wards off any form of depending or intimacy.

Disturbance in Affect Awareness and Regulation

Patients with schizophrenia can experience intense affects, such as fear of attack, fear of disintegration, fear of murderous impulses, and feeling inhuman and monstrous. Because these fears are so intense, they require massive defenses to hide and distort them. These distortions affect not only the awareness of fears, but also the functioning of the ego as a whole. These defenses—to name only a few—include denial of real experiences in the past and present, denial of unwelcome aspects of reality, denial of whole segments of self-experience, primitive projection, and attachment to inner fantasy figures at the expense of relations with actual human beings in the outside world.

There is a particular process I want to highlight: the perceputalization and sensationalization of thinking. Many patients diagnosed with schizophrenia seem to lose the capacity to use conceptual thought. Their thinking seems to be overly concrete, filled with references to body sensations. It is as if abstract concept use has collapsed and has been replaced by percepts and sensations. A patient with schizophrenia I worked with had just suffered a personal loss; her face appeared very sad and filled with grief. When I asked her what she felt, she said that she had a pain in her heart. This was not a metaphor. Whereas she did not feel sad or lonely or emotional pain, she did experience the sensation of a stabbing pain in the area of her left chest. The affect of sadness and the conceptual appraisal of loss that goes with it, seemed to collapse into a physical sensation. This particular defense against affects—and the thoughts which lead to affects—I am calling perceputalization and deconceptualization (I will discuss these processes in greater depth later in this paper). They serve to block out affects and are associated with wide-ranging ego dysfunctions, including hallucinations, concrete thinking, and a form of alexithymia. The ways in which thoughts and emotions are transformed into sensations and perceptions have been discussed in a variety of excellent works including Segal (1957), Searles (1965, 1979) and Marcus (1992).

Patients with schizophrenia are also extremely vulnerable to affect dysregulation. Interactions with other people can induce painful feelings of shame, fear, anxiety and dysphoria, which are defended against by massive interpersonal withdrawal, stereotyped behaviors, or emotional blunting.

Disturbance in Psychological Boundaries

As I noted, patients with schizophrenia use ego-undermining defenses, such as denial of massive areas of self-experience, projection of wholesale aspects of the self, and splitting. Because of these, the boundary is blurred between what is inside and what is outside. This blurring is intensified by the patient’s affective vulnerability. Dan Stern (1985) describes the way in which intersubjective emotional states, especially “mis-attunements” with others, can invade and interrupt a child’s sense of emotional well-being. It is as if there is no barrier shielding the patient from the emotional impact of other people’s behavior. Hurt, disappointment, feelings of coercion and control, and loss seem to penetrate directly into the patient’s heart, without a barrier. This adds to the experience of porosity between the patient’s inner and outer experience.

Disturbance of Symbol Use

It is well known that with schizophrenia, the patient’s use of language can be profoundly disturbed. Many writers have described patients alternately using concrete and over-abstract and stilted language (Goldstein, 1944). Patients diagnosed with schizophrenia often have difficulty using words to describe their inner states. Language is infused with references to parts of the body (Freud, 1915; Isaacs, 1948; Searles, 1962). Words are used idiosyncratically, with meanings that are personal and obscure rather than conventional and public. Words and phrases seem to evoke references which are incomprehensible to the listener, as in looseness of associations. Language use and, more generally, conceptual thought seem to be disturbed in schizophrenia and this seems to block the patient off not only from other people but from the meaning of his internal fantasies and affects. This will be covered in the discussion about perceptualization and deconceptualization.

Disturbance in the Testing of Reality

Patients with schizophrenia have difficulty in all three areas of reality testing described by Kernberg (1975): the discrimination of internal versus external sources of perception, the discrimination of the boundary between self and other, and the appreciation of the social criteria of reality.

Some of the archaic defenses mentioned above may be implicated in these problems. The use of wholesale projection and denial seems connected to the disturbance about what is self and what is other. The absence of an effective barrier against affective influence by the other also may contribute to lack of self-other discrimination.

The use of perceputalization and deconceptualization can lead to confusion about what is thought and what is percept, and thus to a confusion about what is generated by perception of external signals, such as sounds, sights and smell, and what is generated by internal events, such as thoughts, feelings and sensations.

The collapse of conceptual thought may lead to a loss of contact with the concept-based conventional social viewpoint. Our common socially shared world view informs our judgments about what is “appropriate,” what is common, and what is acceptable. This view depends on our ability to participate in the common culture by means of language. When language breaks down we lose our connection with the social point of view of the average, expectable member of the culture. Thus when verbal thinking breaks down, we lose contact with the social criteria of reality.

The Need to Modify Standard Psychodynamic Technique

Before going on to discuss technique, I want to say another word or two about perceputalization and deconceptualization because they have an important impact on the approach to psychotherapy.

Traditional psychotherapy depends on clarification, confrontation and interpretation (Bibring, 1954). Each of these, in turn depends on the patient’s intact capacity to use words and verbal symbols to describe his inner fantasies and affects, to understand the interpretations he hears and to apply the meaning of these interpretations to his inner experience. If concept formation and concept use are interfered with, as I believe they often are in schizophrenia, then the use of traditional psychotherapy is compromised. If words have broken down, a therapy that depends so critically on intact word use is robbed of its power. Traditional forms of psychotherapy can only be applied after the patient’s capacity to use words to describe his inner states and to understand the communications of other people has been restored. Some of the techniques I discuss, especially naming and enlargement, are efforts to help the patient develop a language, or a lexicon, for his inner states. The principle rationale for these techniques is to address the breakdown of symbol use found in schizophrenia.

A final word—do perceputalization and deconceptualization actually exist? Is there evidence that conceptual thought breaks down in patients with schizophrenia in the way that I have described? I think that there is. The following case example illustrates perceptualization and deconceptualization.

Dr. M was questioning Ms. B during a psychotherapy session. She was evasive and vague, and Dr. M’s persistent questions became more pointed. After a time, Ms. B reported seeing an object behind Dr. M’s shoulder. Dr. M encouraged her to describe this object in as much detail as possible. She was able to describe what she perceived—a scouring pad. The object was made of coarse material and it was “rough.” Soon more affect-related words crept into her description—the object was “abrasive,” “irritating,” and finally “pushy.” With a little more discussion Ms. B was able to link her perceptions of the object to the effect of Dr. M’s behavior on her emotions: Dr. M was being irritating and pushy and it made Ms. B angry.

Having described something about the background of my approach, I will discuss some general principles, and then particular techniques in working with patients diagnosed with schizophrenia.

General Principles of Psychotherapy

Respect for Psychic Determinism

Work with patients who have schizophrenia can challenge one’s belief that psychological forces are at work in creating symptoms. Symptoms seem so strange, and so discontinuous with “normal” mental life that they seem to call for a genetic or pathophysiological explanation. Nevertheless, there is considerable evidence that psychological factors play a major role in psychosis (Lotterman, 2015; Hamner et al, 2000, Tienari, 1991). With due respect to the possible organic basis for some symptoms, it is useful to approach the patient as if everything that he is saying or feeling has a psychological meaning. It is fruitful to try to understand his speech, emotions and behavior in terms of its psychological sense. An inpatient psychotherapist worked with a woman with extreme psychosis. She was well known for making long, rambling, incomprehensible speeches during the morning meeting. Her virtual “word salad” could have been understood simply to be a “symptom of schizophrenia.” However, the “salad” turned out to have a meaning. She later explained that she made these speeches to appear “crazy” so that others would not know what she was feeling. Another patient was a woman who was catatonic and mute for five months. She reacted to nothing and seemed utterly beyond reach, in what, to the staff, appeared to be a biologically determined psycho-physiological prison. When the woman recovered she reported hearing and understanding all the conversations that were going on around her. She explained she had not been ready at that point to interact with others and deal with her problems. Her symptoms represented a “psychic retreat” (Steiner 1993).

Monitoring the Interpersonal Relationship

Paying attention to the transference is a hallmark of psychoanalytic treatment. The patient experiences affects and fantasies towards the therapist that repeat important emotional experiences with others. In work with neurotic patients, we assume that these repetitions more or less accurately reflect the nature of previous relationships. This re-experiencing becomes an opportunity to examine these reactions in detail and, in so doing, to learn about the patient’s psychological life.

Examining this kind of transference can be very helpful in psychotherapy with patients who are diagnosed with schizophrenia. But it is also important to examine something which is related but different: the status of the interpersonal relationship. In work with patients who are neurotic the interaction between patient and therapist is, generally, kept minimal, and the focus is not on the concrete give-and-take of a material relationship, but the patient’s affective and fantasized experience of that relationship. The patient understands that he is distorting his perceptions according to his psychological needs—that the relationship is a kind of play. He is able to appreciate that his experience of the therapist, and the way the therapist is in reality, are not necessarily the same.

This transference experience is different in two ways with patients who are psychotic. First, the therapist becomes materially involved in the patient’s life in a way he does not with a neurotic patient: if he is a psychiatrist, he prescribes medication, he gives advice, he offers suggestions, warns of ominous consequences to destructive behavior, and so on. The therapist often becomes more of an actor in the life of the patient with psychosis than he does with a patient with neurosis. The patient will sometimes react to the therapist’s involvement with great intensity. The patient may dramatically distort his perception of everyday events and respond impulsively with unforeseen consequences. For example, a patient was having a conflict with his employer and felt that her boss and coworkers were “against” her. She cited various rather unremarkable office interactions as “proof.” She wanted Dr. D to be her emotional ally in this struggle. Dr. D expressed sympathy about her feelings, but stopped short of proving loyalty to the patient by endorsing her view of reality. The patient experienced this as an abandonment and she broke off treatment. While there were transference aspects to this interaction, there were also “realistic” ones. Dr. D was expressing sympathy and giving advice (not to act impulsively). But what Dr. D offered by way of sympathy apparently was not enough for the patient, who became furious.

It is very important that the therapist keep an eye on the possible consequences of any interaction, especially those that may lead to disappointment, loss, a feeling of insult, abandonment, criticism or rejection. We could call this the “negative interpersonal reaction” in order to distinguish it from the negative transference. In thinking about negative transference there is focus on the ways in which the patient’s perception of the therapist is distorted and influenced by unconscious fantasy. In the negative interpersonal reaction there is focus on the ways in which the patient’s puzzling emotional responses are a meaningful response (albeit often hidden and obscure) to what is actually going on with the therapist in the present moment. Disappointment, anger, hurt, and fear are deeply felt by patients with psychosis even if they are not always conscious, and this can lead to abrupt, unexpected, and permanent ruptures in the relationship. These reactions not only spring from a confusion on the patient’s part to whether the therapist is or is like another person in his life; but it also can spring from the experience of how the therapist is actually treating the patient here and now—even if awareness is blocked by repression, dissociation or denial. It is important for the therapist constantly to keep in mind questions such as: “What kind of relationship do I have with the patient now?” “Does he feel supported and well treated? Or is he upset?” “Is he envious?” “Does he feel hurt or abandoned?” “How do these emotions affect his willingness to reveal what he feels to me, or even whether he is willing to continue the relationship at all?”

Insofar as the patient’s interpersonal reactions to the therapist are discussed and made conscious, they may act as “silent resistances,” building up over time and finally exploding in the form of action, such as hostility towards the therapist, refusal to reveal oneself in depth, or, finally, refusing treatment altogether. This outcome may sometimes be forestalled by careful and systematic monitoring and discussion of the interpersonal conditions of the relationship.

Monitoring the Countertransference

Scores of writers have emphasized the importance of countertransference in work with patients, especially disturbed patients (Freud (1912), Heimann (1950), Rosenfeld (1952), Little (1957), Bion (1967), Racker (1968), Kernberg (1975) and Searles (1979).

Arlow (1980) wrote, “No matter now distant the context of his thoughts may seem from the patient’s preoccupations, he (the analyst) nevertheless appreciates them as clues or signals pointing to the unconscious meaning of the patient’s communications”(p. 204).

While countertransference emotions and fantasies are important in work with patients who have neuroses (and even more so in work with patients with borderline disorders), they are critical in work with patients diagnosed with schizophrenia. In many cases, the countertransference is the only place where some of the patient’s crucial emotions and fantasies will appear in the treatment. The patient often projects or induces these experiences into the therapist to rid himself of the burden of feeling them, and of the work of becoming conscious of them by capturing them in words or images. Baring feelings and translating them into words requires a capacity to tolerate pain and anxiety that the patient may not feel he has.

Patients with schizophrenia often seem not to feel much at all. Their affects appear to be flat and/or restricted. Their capacity to feel emotions seems to have broken down. When they do have emotions, they often seem to be hardly bearable at all. They can feel an intense form of emptiness. One patient, Ms. W, said, “The feeling of missing people is torture—not physical torture, but mental torture.” Some patients feel deadened, as if they have no emotional life whatsoever. Ms. W went on to comment, “At times, it’s like I am a huge expanse of nothing. I don’t feel human when I’m alone.” Another patient, Mr. A, said, “I am barren. There is nothing inside to give anyone.”

I mention these feelings to emphasize that feelings of deadness, or feeling that one is like a hideous monster, may not be bearable for a patient, and extreme defensive operations are used in order to protect him-or herself. Among these extreme defenses are denial and emotional induction. In effect, patients extrude these unbearable experiences into the therapist.

The ability of the therapist to accept, tolerate, live with, and, ultimately, be conscious of these emotions is decisive for psychotherapy. The therapist must, in effect, become an auxiliary ego whose functions consist of affect tolerance, affect awareness, and affect translation into verbal concepts. I think that one of the many reasons why psychotherapy with patients with psychosis has fallen out of favor is that this work can be very painful for the therapist (Searles, 1979, p. 285; Karon 2003). Feelings of hopelessness, repulsiveness, deadness, worthlessness, and self-doubt are frequent in work with patients diagnosed with schizophrenia. Every therapist who is deeply connected to his patients will feel them too.

Specific Techniques

Emotional Induction

The familiar explanation of the phenomenon countertransference invokes the concept of defense of projective identification. But projective identification was originally conceived to be a fantasy on the part of the patient about introducing unwanted aspects of the self into the other (Klein, 1946). Later, Bion (1956) described an interpersonal aspect involving the emotional response of the other. But neither description accounted for the mechanism of inducing affects into another person (Fenichel, 1945; Kernberg, 1984). I have used the term “emotional induction” to describe the behavioral mechanism that a patient uses to stir up a predictable emotional response in those around him (Lotterman, 1990).

Briefly put, a patient behaves in ways designed to evoke characteristic and predictable feelings in the therapist. Like a playwright, the patient arranges a series of actions, and interpersonal situations which generate expectable emotional responses. The patient sets a chain of events in motion which has a foreseeable emotional impact on the therapist. T. S. Eliot described this form of communication:

Patients can be very adept at using the methods of theater: expression through body posture and movement, staging (the arrangement and timing of action), delivery (vocal dynamics and tone), props and costume. Each of these nonverbal tools can stir up strong emotions and ideas that communicate his emotional experience to the therapist. Often, there seems to be an inverse relation between the patient’s ability to recognize and report his inner life and his use of nonverbal methods to communicate to the therapist.

For example, at a time when the therapist, Dr. C, wanted to talk, Ms. W arranged meeting after meeting, only to find one excuse after another not to show up. All the excuses were plausible, but nevertheless Dr. C felt increasingly annoyed, helpless, and anxious. She spoke to Ms. W.

Dr. C: I feel frustrated. I was eager to start our session, but I felt I didn’t have any control over when you’d get here.

Ms. W: Control is something I never have here. Now you feel some of what I go through every day.

Disclosure of Induced Emotion

In the last example, the therapist revealed her emotional reactions to the patient. What is the rationale for this, and why is it helpful?

Patients will often block out affects which are central to their lives and to their symptoms by means of denial and primitive projection. They deposit these emotions via emotional induction in the therapist. If the therapist decides that he will not disclose his personal reactions to the patient either out of a concern about causing pain or because he does not want to burden the patient with his personal emotions, then emotional data, which is crucial for psychotherapy, may be lost. It will remain buried in the therapist’s countertransference reaction. The patient will have found a safe harbor to hide essential emotional information. The patient would have made use of the therapist’s concern about being “tactful” or “neutral” or “abstinent” in the service of resistance. To not communicate these reactions, is to collude with this resistance.

It is very useful that the therapist demonstrate the ability to tolerate and to put words to difficult emotions, and to show that this is possible without causing a catastrophe. The therapist can model the crucial skills of affect tolerance and communication, which are so important for the patient. The therapist is also modeling the ability to be frank and direct in talking about emotions and opinions, without being impulsive, hostile or defensive.

Here is an example of disclosure:

Dr. T had worked on an inpatient unit for several years and treated Ms. R. Their work had been very productive, but Dr. T was graduating and decided to leave the unit to take another position at the hospital. Ms. R was aware of this change, but the two had had little chance to talk about it. Ms. R had missed four of five sessions in a row. Dr. T thought about his own emotional reactions before speaking to Ms. R when they met.

One might be concerned that if the therapist communicates his emotional experience (especially if it involves feelings of anger, or fear or disgust), that the patient might be frightened, burdened, or overwhelmed. Or, perhaps the patient might experience this communication concretely and believe that the therapist’s overall and enduring reaction to him is one of anger, fear, or disgust. In practice, however, I have not had this experience. If I clearly explain to the patient beforehand that the emotions I am sharing give us information about what is happening between us, the patient is almost always able to collaborate in exploring what this means. I believe that patients are also reassured that though I may feel these “negative” emotions at times, that they do not overwhelm me or dominate my overall response. The therapist’s ability to do this can model a tolerance for affects and encourage the patient to tolerate his own unwanted emotions. It is part of the therapist’s job to sort out which emotions have more to do with his own personal emotional life (and past) and which are related to his experience with the patient. While sometimes challenging, this is not an impossible task.

Sometimes the therapist’s disclosing emotion helps the patient develop confidence in his ability to appreciate what is real. Here is an example:

Without revealing to Mr. M (or burdening him) with the details, Dr. O confirmed Mr. M’s accurate interpersonal perception. In doing so, he demonstrated the safety and benefits of revealing oneself to another person and also helped increase Mr. M’s confidence in his own ability to appreciate what is real.

The therapist’s disclosing of emotion may play an important role in helping to define the boundary between patient and therapist. In the example of Mr. M above, Dr. O’s disclosure that he was sad confirmed the patient’s ability to perceive the emotional state of someone other than himself.

Object Definition

In psychodynamic work with patients who have neurosis, it is often helpful for the therapist to be a rather indistinct figure. One wants to give the patient ample room to use his imagination to allow fantasies and emotions from the past to enter the picture. This is the rationale for therapeutic abstinence and anonymity.

In work with patients with psychosis, the boundary between the patient and the therapist may be unclear. The patient may feel that the therapist is feeling what he feels, or that he can treat the therapist or his things as his own possessions, or that he is entitled to intrude into another person’s personal realm. The problem of where the boundary is between one’s self and the self of the other is crucial for many patients with psychosis. The fact that this boundary is not clear, may sometimes be very gratifying to patients, and lead to feelings of merger and oneness. At other times it may provoke terrifying anxiety connected with loss of personal identity and annihilation. Patients will often push the therapist to the point where the boundary is clarified or the relationship breaks down.

Here is an example: Ms. Y was in Dr. A’s office. She was being provocative—crawling on the floor, rifling through the therapist’s files, and unplugging the telephone.

Naming

The difficulty in putting the inner experience into words has a profound impact on the conduct of psychotherapy with patients diagnosed with psychosis (Searles, 1965, pp. 560-583). There is no possibility of promoting psychological change if emotions and fantasies remain hidden and unexamined. Patients are often aware that their emotions are buried. Mr. A said that his emotions were “too submerged, too far underground” to utter. Mr. G said that it was “tough to get a hold of an idea and bring it to my lips.” Patients often dismiss inquiry into what they feels with a cursory “I don’t know” or “I can’t think.”

The technique of naming consists of a persistent, determined effort to help the patient identify sensations, perceptions, and body experiences which may embody essential thoughts and emotions. By paying vigilant attention to the details of the patient’s experience, and by translating the details of that experience into words, the patient’s inner life may be clarified and shared. What begins as concrete perception may be transformed into emotion, thought and meaning. If this is successful, it may pave the way to a more traditional form of psychodynamic therapy based on word and concept use.

Here is an example:

Enlargement

Enlargement is an extension of naming, but assumes a broader language for internal states. It is similar to psychoanalytic clarification in that it asks the patient to describe his experience in greater detail. Unlike clarification though, there is a greater effort to pay attention to a detailed description of the sensation or emotion or the experiences associated with them. If a patient feels like breaking off a description, he may be asked to persist. If a patient “has no more thoughts” about a subject, he may be asked to continue to pay attention to his inner experience anyway. The purpose of enlargement is to help reverse the breaking of conceptual and associative links that often characterizes schizophrenic thought (Bion, 1959). Often, emotions and ideas will emerge from this kind of focused description and association.

Both enlargement and naming are unlike free association in that the therapist is asking the patient to describe specific, emotional experiences in greater depth and detail, not to move on, via a linked chain of thoughts, to other experiences which are meaningfully connected.

Here is an example: Ms. G said that her emotions were “interred.” This struck Dr. E as a curious way of putting it. When asked about it, Ms. G shrugged the expression off as just a “figure of speech.” But Dr. E persisted, and asked about the various possible meanings of “interred.” Did Ms. G mean “dead” as in an interred body? Or did she mean buried under a great weight, but possibly still alive? Or did she mean trapped or imprisoned, waiting for an obstacle to be removed so she could be free? As Ms. G responded to these questions, information surfaced about how she felt cut off from people and how she felt dead inside. She also talked about how helpless she felt, and how hopeless she felt about ever being “found” by anyone after years of emotional isolation. The term “interred” captured very well the various colorings of her particular experience of her relationships.

Limitations of space do not permit a discussion of other important symptoms of schizophrenic psychosis such as hallucinations, delusions, and looseness of association. An understanding of the psychological structure of patients diagnosed with schizophrenia can guide an approach to these phenomena as well. A more detailed description of this approach appears elsewhere (Lotterman, 1996 & 2015).

Conclusion

This has been a brief description of my approach to psychotherapy with patients with schizophrenia. Work with these patients can be very difficult, very taxing, and, at times, very discouraging. But it is certainly possible to establish relationships in depth with patients with psychosis which can have all kinds of useful results. On the more modest side, the relationship can help a patient to follow his treatment plan more consistently and to take his medication, if indicated, more regularly. In some cases, it can help patients not only reduce psychiatric symptoms, but also to come out from profound social isolation, and resume work, schooling, and even romantic relationships. The path is never easy or straight, but, it can often be deeply rewarding.